Framework for analysing risk and safety in clinical medicine

Vincent, Charles; Taylor‐Adams, Sally; Stanhope, Nicola

doi:10.1136/bmj.316.7138.1154

Cited by 761 publications

(620 citation statements)

References 16 publications

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“…Multiple factors influence the rate of medical errors in complex healthcare system, the major factors relating to the institutional context, organisation and management, work environment, care team, individual team member, task and patient. 17 In response to an open ended query about what is most needed to improve safety and efficiency in the operating theatres, two thirds of doctors and nurses cited better communication. 18 Though both the study samples agree on lack of communication leading to adverse events, significant difference exist in relation to other factors as mentioned.…”

Section: Discussionmentioning

confidence: 99%

A survey of attitude of frontline clinicians and nurses towards adverse events

Chakravarty

2013

Medical Journal Armed Forces India

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Medical errorAdverse events a b s t r a c t Background: It is often said that doctors are only human. However, technological wonders, apparent precision of diagnostic tests and scientific innovation have created an expectation of perfection from medical science. Patient safety and prevalence of adverse events on the hospital floor have become issues of serious concern for the healthcare environment.Method: The study had cross-sectional design, done over a period of one year at a teaching medical college and its affiliated hospitals. The study instrument was an anonymous, voluntary 5-point Likert scaled questionnaire and study sample was selected by simple random sampling into two groups of front-line clinicians (n ¼ 175) and nurses (n ¼ 60). The questionnaire was analysed for its reliability, construct and content validity. Subsequently, the data was entered into an Excel Spreadsheet and further analysed by statistical software SPSS version 16.Results: Total of 175 front-line clinicians and 60 nurses completed the survey for response rate of 96%. The study instrument was suitably validated for its psychometric properties. Statistically significant differences were observed between the two study samples across certain attitudinal statements, the important ones being responsibility for reporting and comfort level towards disclosing adverse events. Surgical site infections, Medication errors and Patient Falls were the commonly observed adverse events and lack of communication among team members was identified as a major factor leading to adverse events. Conclusion:Effective attitude-based interventions need to be developed, where the attitude and culture of front-line healthcare workers can be explicitly targeted for inducing desirable behavioural changes towards improved patient safety.ª 2013, Armed Forces Medical Services (AFMS). All rights reserved.

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Section: Discussionmentioning

confidence: 99%

A survey of attitude of frontline clinicians and nurses towards adverse events

Chakravarty

2013

Medical Journal Armed Forces India

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“…Although the NPSA does not mandate a particular process or toolkit, its training and website point to the "London Protocol" (Vincent et al 1998). According to this, RCA investigations should be undertaken by a small nominated team convened by the quality co-ordinator or patient safety officer and guided by a facilitator.…”

Section: Root Cause Analysis In Healthcarementioning

confidence: 99%

“…A common way to investigate clinical incidents is through Root Cause Analysis (RCA), a methodology combining elements from engineering, psychology, and the "human factors" tradition (Reason, 1990;Vincent et al, 1998). As indicated by its name, RCA directs analytical attention to the root or latent factors that condition, enable or exacerbate clinical risk with the aim of producing recommendations on how these underlying causes should be managed or eradicated (Carroll et al, 2002).…”

Section: Introductionmentioning

confidence: 99%

Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap

Nicolini

Waring

Mengis

2011

Social Science & Medicine

112

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Publisher statement: NOTICE: this is the author's version of a work that was accepted for publication in Social Science and Medicine. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in Social Science and Medicine, 73(2), (2011) POLICY AND PRACTICE IN THE USE OF ROOT CAUSE ANALYSIS TO INVESTIGATE CLINICAL ADVERSE EVENTS: MIND THE GAP AbstractThis paper examines the challenges of investigating clinical incidents through the use of Root Cause Analysis. We conducted an 18-months ethnographic study in two large acute NHS hospitals in the UK and documented the process of incident investigation, reporting, and translation of the results into practice. We found that the approach has both strengths and problems. The latter stem, in part, from contradictions between potentially incompatible organizational agendas and social logics that drive the use of this approach. While Root Cause Analysis was originally conceived as an organisational learning technique, it is also used as a governance tool and a way to re-establish organisational legitimacy in the aftermath of incidents. The presence of such diverse and partially contradictory aims creates tensions with the result that efforts are at times diverted from the aim of producing sustainable change and improvement. We suggest that a failure to understand these inner contradictions, together with unreflective policy interventions, may produce counterintuitive negative effects which hamper, instead of further, the cause of patient safety.3

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“…Reason and Vincent et al have pointed out that frontline workers are ''the inheritors, not the instigators'' of errors; thus, human error is a symptom or, even more strongly, a consequence of system problems, not a cause of undesired outcomes. [8][9][10] Their view is that systems call forth from workers behaviors that are later called errors, not the other way around. 11 To paraphrase Rochlin, 12 for a caregiver in an emergency, unsure of context and pressed into action only when something has already gone wrong, with an overabundance of some data but missing the rest and under pressure to act quickly, avoiding a mistake may be as much a matter of good luck as good training.…”

Section: Beyond Errormentioning

confidence: 99%

Beyond Error

Wears

2000

Academic Emergency Medicine

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Framework for analysing risk and safety in clinical medicine

Cited by 761 publications

References 16 publications

A survey of attitude of frontline clinicians and nurses towards adverse events

A survey of attitude of frontline clinicians and nurses towards adverse events

Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap

Beyond Error

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